Provider Demographics
NPI:1780955724
Name:GENESIS REHAB
Entity type:Organization
Organization Name:GENESIS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:904-284-5606
Mailing Address - Street 1:803 OAK ST
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-4317
Mailing Address - Country:US
Mailing Address - Phone:904-284-5606
Mailing Address - Fax:
Practice Address - Street 1:803 OAK ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4317
Practice Address - Country:US
Practice Address - Phone:902-284-5606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5201314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility